IBTICM Multi-source feedback - Ashford and St. Peter's Hospitals ...
IBTICM Multi-source feedback - Ashford and St. Peter's Hospitals ...
IBTICM Multi-source feedback - Ashford and St. Peter's Hospitals ...
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<strong>IBTICM</strong> <strong>Multi</strong>-<strong>source</strong> <strong>feedback</strong><br />
(ICM MSF)<br />
Name of trainee: Year of Training:<br />
Assessor details Male Female GMC No:<br />
Doctor specialty Date / /<br />
Consultant<br />
Nurse<br />
(Theatres/PACU)<br />
SAS Grade Nurse (ICU/HDU)<br />
SpR 4-5 (<strong>St</strong>R 6-7) Nurse (Ward)<br />
SpR 1-3 (<strong>St</strong>R 3-5) ODP<br />
<strong>St</strong>R 1-2 (CT 1-2) Admin/Secretarial<br />
FY 1-2 Other<br />
Please TICK to indicate the<br />
st<strong>and</strong>ard of the trainee’s<br />
performance in each area<br />
Maintaining trust/professional<br />
relationships with patients<br />
• Listens<br />
• Is polite <strong>and</strong> caring<br />
• Shows respect for patients’<br />
opinions, dignity <strong>and</strong> confidentiality<br />
• Is unprejudiced <strong>and</strong> dresses<br />
appropriately<br />
Verbal communication skills<br />
• Gives underst<strong>and</strong>able information<br />
• Speaks good English, at an<br />
appropriate level for the patient<br />
Team working/working with<br />
colleagues<br />
• Respects others’ roles <strong>and</strong> works<br />
constructively in the team<br />
• H<strong>and</strong>s over effectively <strong>and</strong><br />
communicates well. Is unprejudiced,<br />
supportive <strong>and</strong> fair<br />
Accessibility<br />
• Is accessible<br />
• Takes proper responsibility<br />
• Only delegates appropriately<br />
• Does not shirk duty<br />
• Responds when called<br />
• Arranges cover for absences<br />
Comments<br />
• Please use the free text part of this form to comment on<br />
particularly good behaviour or any behaviour causing<br />
concern<br />
• If you want to comment on attitude please provide<br />
evidence of behaviour. This should reflect the trainee’s<br />
behaviour over time – not usually a single incident.<br />
• The trainee will receive private <strong>feedback</strong>, but you will not<br />
identified<br />
• If enough observers regard a trainee as giving cause for<br />
concern they will be offered help <strong>and</strong> support<br />
Areas of concern<br />
None Some Major<br />
Cannot<br />
comment
<strong>IBTICM</strong> <strong>Multi</strong>-<strong>source</strong> <strong>feedback</strong> (ICM MSF)<br />
Date<br />
Dear Colleague<br />
Trainees in Intensive Care medicine – <strong>Multi</strong>–<strong>source</strong> <strong>feedback</strong><br />
<strong>Multi</strong>–<strong>source</strong> <strong>feedback</strong> is now a required part of the assessment process for trainees<br />
in intensive care medicine <strong>and</strong> we would be grateful if you would take a few minutes to<br />
complete the attached form.<br />
The form is anonymous but we ask that you complete a limited number of personal<br />
details to enable us to check that a suitable cross-section of people have been asked<br />
to comment on the trainees’ performance.<br />
Please return the form to -------------------------------------------------------in the envelope<br />
provided by (add date)-------------------------.<br />
Thanks you for agreeing to complete this multi-<strong>source</strong> <strong>feedback</strong> form.<br />
Yours faithfully,<br />
-----------------------------------------------------------<strong>IBTICM</strong><br />
(add name)
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